Our official 2021 guide to understanding Obamacare and Pa health insurance will help you shop and compare the best policies, find the best prices, and purchase the plan that’s the right fit for you. Although Pennsylvania healthcare reform and federal tax subsidy changes each year make the “Exchange” process a bit more confusing, we’re confident you will save money. The new Pennie state-based Marketplace helps single persons and families purchase coverage in the Keystone State.
A lot of things changed, so we’ll summarize them. Perhaps the most significant change is that applicants are no longer declined because of a single or combination of medical conditions. Whether it is heart disease, degenerative back issues, diabetes, mental illness, obesity, or any type of cancer, you can purchase health insurance in Pennsylvania. You can also buy non-Obamacare plans, that are often less expensive, although several benefits are not included.
Smoking continues to be considered in the determination of rates. So, if you use nicotine, you will pay more than many other persons. But you will not be denied. Height and weight have been removed from Marketplace underwriting guidelines, although non-compliant “short-term” plans can use your BMI when determining your premium. The medications you take, and surgery history, do not impact the cost of coverage. Prior coverage is not required to secure the best rate. Billing is monthly with no extra cost for paying via mail. You may change plans every year and qualified dependents may remain on your policy until they reach age 26.
Can you keep your plan and doctor? Sometimes, but not always. Many persons were forced to switch plans and benefits when the Legislation was passed. Cheap non-compliant policies without maternity coverage were no longer “legal,” even though many households did not want or need specific benefits. And companies initially fled the Marketplace, including giants Aetna, Humana, and UnitedHealthcare. Often when carriers no longer offer plans in an area, customers much switch doctors, specialists, and sometimes hospitals. UnitedHealthcare has returned to offer Exchange coverage in several states, and Aetna is expected to begin offering ACA plans in 2022 in selected states.
Pennie is the new state-based healthcare marketplace that replaces the federal marketplace in the Keystone State. Premiums have slightly reduced because of the savings of operating your own Exchange, and the Open Enrollment period was extended to January 15th (instead of December 15th). Customer service assistance will be localized and experienced and respected websites (like ours) continue to offer direct seamless enrollment with no fees or costs.
Senior Pa Healthcare
If you have reached age 65, you are no longer eligible for Marketplace coverage. Senior medical coverage, however, is offered through Medicare, or possibly your employer, if you are still working. You can also choose to add Medigap benefits, which consist of standardized Supplement plans, or Advantage plans, that replace original Medicare. An annual Open Enrollment is provided between October 15th and December 7th. In many situations, you can change plans without medical underwriting.
If you are retired, and your past employer offers medical benefits, it is possible that no additional supplemental coverage is needed. Also, many persons are satisfied with their original benefit, and feel additional protection is not needed. You can change from one Supplement policy to another, and also change Part D and Advantage plans during designated times each year. A new Plan G High Deductible (HD) plan is offered. After the $2,300 deductible is met, typically, benefits are paid at 100%.
Your Household Income Counts!
Your household income is still a factor in determining how much you pay. As you probably correctly assumed, the more money you make, the less help you’re going to receive from Uncle Sam. The new federal subsidies are based on the National Federal Poverty Level, also known as the FPL. 2021 FPL guidelines use 2020 levels.
Current levels are $12,760 for a single household, $17,240 for a two-person household, $21,720 for a three-person household, $26,200 for a four-person household, $30,680 for a five-person household, and $35,160 for a six-person household. Since up to 400% of NFPL receives a subsidy, a family of four with income under $98,000 (can vary by state) can potentially receive financial aid. Amounts above that will not receive any help, unless there are additional dependents. The Census Bureau updates these figures each year.
If you don’t qualify for financial aid, buying non-Exchange plans should be considered. These policies often have bigger provider-participation networks, so you have more flexibility regarding which physicians, specialists and facilities to use. Also, several carriers, including UnitedHealthcare, offer policies in many states, but only “off” the Marketplace. However, their Group plans through employers are generally available in many more states, including the Keystone State.
Many “temporary” plans can be purchased away from the Marketplace and are much less expensive than the typical policies that are available during Open Enrollment. But pre-existing conditions are not covered on these short-term contracts, and unlimited benefits are replaced by caps between $100,000 and $2 million. UnitedHealthcare, IHC Group, and HCC Life (Tokio Marine Group) offer very competitive prices in most counties. Companion Life offers many indemnity plans in selected states with very low pricing. An indemnity plan allows you to visit any provider.
I Hate To Ask, But Are My Rates Going To Go Up?
For many consumers, they will. Many persons in lower income brackets will see smaller increases, or possible substantial decreases with the help of the tax breaks. Moderate to high-income families and individuals may see prices spike up, although each situation is different. We review your circumstances and offer advice that will keep your rates as low as possible. The health of each family member is considered.
Six years ago, the first year of the change, there were increases. 2020 also has increases, although not every policy (or company) is charging higher rates than previous years. We will continue to inform customers which plans are the best bargains, and the policies that do the best job of paying the claims that are most likely to be filed. When new carriers become available, we review the available plans in your service area.
The “Bronze” Metal plans remain the cheapest option, since the deductibles and coinsurance are typically the highest. Many companies offer an HSA option which allows you to tax-deduct additional contributions and also receive negotiated lower pricing from the insurers. You can also utilize HSA accumulations to help pay Senior expenses that Medicare may not cover. A high deductible (HD) Plan F and G is offered and is the least expensive Supplement plan. Typically, you pay $2,300 of expenses before benefits are provided.
We like this specific option, especially if you don’t need unlimited office visit benefits. Preventive costs are always covered at 100%, and for many individuals and families, that represents most of your expenses for the year. You can also change from one type of plan to another, every year during Open Enrollment (see below). However, if you replace your HSA with a non-HDHP plan, you can no longer make tax-deductible deposits, or pay for healthcare, vision, and dental expenses with tax-deductible dollars.
When Is Open Enrollment?
Open Enrollment begins on the first day of November and continues through December 15th. During this time, you can apply for an Exchange policy. To secure a January 1 effective date, enrollment must be completed by December 15th. Otherwise, without an SEP exemption (see below), a non-Obamacare plan will have to be selected. Every year, a new OE period begins. If you reach age 65 and become eligible for Medicare, the OE period begins in October.
Special circumstances (divorce, termination from a plan etc…) will allow you to enroll at different times throughout the year, even if it is not during the official designated time period. These “Special Enrollment Periods” provide 60 days to review, compare, and choose a plan. All Marketplace rules apply, so you will not be asked medical questions, and federal subsidies will be available (except for “Catastrophic” plans).
A full list of “Qualifying Life Events (QLE) are provided upon request. Divorce, a dependent reaching age 26, moving to a different service area, and losing qualified group benefits are common examples.Other situations that qualify include losing CHIP, Medicare or Medicaid benefits, a seasonal worker that moves from or to the place they are working, and having a baby or adopting a child. However, although the newborn baby qualifies, an uncovered mother may not qualify.
Persons that forget to enroll, must keep their existing qualified plan if they want to retain Marketplace coverage. A voluntary cancellation of that coverage will not create a QLE. Moving to a different residence within the same county or zip code generally will not qualify. Once coverage lapses, non-Marketplace plans are available, but federal subsidies are not offered.
What Happens If My Employer Drops Their Company Plan?
If your employer no longer offers healthcare benefits to you, you will be notified in advance and will have enough time to apply for coverage through our website or the Federal Exchange. Duplicating the exact copays, coinsurance and deductibles probably will not be possible, but you will not be declined, regardless of any medical issues. You will, however, retain most (or all) of your “Cadillac” benefits since essential benefits must be included on all plans. Maternity, mental illness, prescription drugs, and office visits are all required benefits.
You will also be eligible for a federal subsidy, which you were not receiving while covered on your employer’s plan. You must estimate your household income for the upcoming year to determine how much financial aid you will receive. If there is a substantial change in income during the year (promotion, job loss etc…), you can request to adjust the amount of the subsidy you are receiving. If you reach age 65, you probably will become eligible for Medicare, although you are not required to purchase Medigap coverage.
If I Am Not Eligible For A Federal Subsidy, Which Are The Best Pa Health Insurance Plans To Buy?
Let’s first show you the maximum amounts of household income that will result in no financial aid. We used Allentown (Lehigh County and Zip Code 18101) for our example. Other cities and counties will have slightly different results. Shown below are the estimated income levels, that if reached, will result in no subsidy eligibility. Income amounts under these levels should result in financial aid.
$50,000 – 25-year-old single person.
$50,000 – 35-year-old single person.
$50,000 – 45-year-old single person.
$50,000 – 55-year-old single person.
$68,000 – 35-year-old married couple.
$68,000 – 45-year-old married couple.
$68,000 – 55-year-old married couple.
NOTE: Unless you are being treated for an injury or sickness that requires expensive medications and/or specialist visits, a “high-deductible” HSA policy can be a big cost-saver. Most of the companies participating in the “Exchange” offer an HSA-type of option. Deposits into the HSA can also be used to pay for qualified dental and vision expenses. Once eligible for Medicare, although additional deposits can not be made, accumulated funds can be utilized for approved expenses.
You can also purchase policies “away” from the Exchange. These plans are quite economical and are a nice contract to consider if all of the applicants are in excellent health. Sharing of personal financial information with the government is avoided, which is a major concern for many consumers. Although no financial subsidies are offered, each Marketplace plan must include all “Essential Benefits,” cover pre-existing conditions, and be available during Open Enrollment and SEP periods.
Originally, the White House estimated that prices would be less than the figures that the Congressional Budget Office (CBO) predicted. For example, a person in their mid-to-late 20s would pay about $185 per month. A married couple with two children would pay about $650-$700 although subsidies could reduce the cost.
After many hours of research and evaluating prices, we have concluded that while in some areas these projections are accurate, in other parts of the state, the offers are different. Our concern is what will happen in 2021 and beyond. If the trend of losing participating companies continues, competition (which helps stabilize rates) will no longer be present.
Are Navigators Helpful?
It depends. If you don’t have access to a website like ours, or you prefer someone visit you at your house, they may be helpful. And despite their inexperience and lack of significant training, many communities utilize their outreach services. But they can not discuss why a specific policy may be best for your needs, or the financial impact of different Metal plans on your income.
Typically, navigators are not insurance-licensed and lack the knowledge of experienced healthcare brokers. They also do not represent non-Exchange and off-Marketplace providers, which is important for consumers that are evaluating all options. However, only qualified plans offer federal subsidies.
In the Allegheny County area, lack of training has kept many navigators from offering their help. Mental Health America and AIU are two organizations that have received federal funds. There are also “counselors” that can help, but they only receive five hours of training. Oddly, many consumers will have more Exchange knowledge than the counselors! We feel that a few weeks (or months) of training is simply not enough time to be advising consumers on very complex scenarios.
What If I Move? For Example, From Harrisburg to Pittsburgh?
If that occurs, you should get ready to buy some Steelers, Pirates and Penguins t-shirts because you don’t want to miss out on all of the fun! And of course, a visit to Primanti Brothers for some french fries on your sandwich is a must!
Seriously, a move will not impact your eligibility or jeopardize existing benefits that you currently have. It is possible that the price of your policy could change, since rates often vary, depending on the county where you reside. For instance, prices in Dauphin County may be slightly less than Allegheny County rates, although the difference would not be substantial. Neighboring counties can also have different plan options. For example, Philadelphia, Montgomery, and Chester County plans are not identical.
However, it is possible that a separate set of carriers may offer benefits in differing locations. For instance, Capital Blue Cross and Geisinger are available in Harrisburg but not Pittsburgh. Conversely, UPMC prices are affordable, and Highmark has a large number of providers in the Western part of the state, but not in Harrisburg. Non-Obamacare plans should not be impacted. If you start a new policy, the anniversary date may be different, and prior medical expenses may not count towards the new deductible.
What About Some Of The Obamacare Myths?
There are plenty of myths. For instance, by now, you know it is not true that everyone can keep their existing coverage, although it’s been six years since you originally heard that claim. It is also not accurate to say that healthcare costs have reduced. So far, we have not seen evidence of that happening. Also, in fairness to the legislation, many consumers have been helped, and millions of persons have become eligible for Medicaid, that were not previously eligible. That is a big money-saver if you fall into that category.
Also, there were not any “death panels,” that mysteriously decided who shall live and who shall die! But it is true that ultimately, you will not have control over all of your healthcare expenditures (although you didn’t before). It is safe to assume that you definitely have less influence on your overall treatment, and the number of available trained doctors may be reducing.
However, although most small business owners are NOT reducing the size of their staff, many have ceased hiring new employees until they understand the impact of future healthcare costs. Keeping their existing benefit packages or eliminating all group medical benefits is always a possibility.
We will continue to keep you updated on any Obamacare changes that affect Pennsylvania.
UPDATES FROM THE PAST:
Cancellation letters continue to be received by policyholders, informing them their existing plans will be terminated since they don’t meet the strict guidelines and basic requirements of the ACA. Although many persons want to keep their basic contracts, even with the White House offering some flexibility, they may not be able to. Bare-bones plans are very popular because of their low cost, and most policyholders are reluctant to give them up.
Navigators in Pennsylvania (VERY different from brokers) provide basic information to consumers. They have limited training and no criminal background checks are required as a condition of their employment. Many are recently-trained. Thankfully, that may change if Senate Bill 1268 becomes legislation. Consumer protection will get a badly-needed boost upon passage.
“Navigators” have access to personal confidential financial information, and therefore it is critical that they receive comprehensive training that is much more extensive than they receive now. Most consumers prefer to work with experienced brokers and/or websites, since they provide much more detailed and expert advice.
With the expansion of Medicaid, about one in five Keystone residents is receiving Medicaid benefits, and 250,000 of those persons are first-time recipients. Many more individuals are expected to become eligible before 2016 since the threshold is now income less than 138% of the Federal Poverty Level (instead of 100%).
Managed plans cover most Medicaid plans in Pa. The main insurers that offer coverage are Aetna, UPMC, and Gateway. Recently, the federal government proposed some changes that may increase network-availability for patients, which is always a concern.
Obamacare is here to stay. Right? Probably, but if the Supreme Court rules that federal subsidies can only be paid in states that operate their own Exchanges, Pennsylvania would lose about $80 million each month in financial aid. Rates for some households could easily double or triple.
If this occurs, a contingency plan is being discussed by Governor Wolf that would create a state-based Exchange, although implementation could take more than a year. Within the next 45 days, we should have a ruling.
UnitedHealthcare and Aetna will not be offering single or family Marketplace plans. Although off-Exchange options may be available, substantial underwriting losses in previous years forced the decision. In the Philadelphia area, Independence Blue Cross is the only viable Marketplace option, since all other carriers have left. However, their rates continue to soar, as they requested a 20.32% rate increase for Personal Choice Exchange EPO plans, and a 24.30% rate increase for Personal Choice Exchange PPO plans. Ouch.